NHS dental crisis- can the rot be stopped?

New figures reveal over 40 per cent of the population has no NHS dentist. Can a new review finally fix the system once and for all?

Not that long ago we were queuing in the streets for an NHS dentist, with scenes of hundreds of patients camping overnight likened to the January sales. Now, new figures suggest that many of us have given up, and are paying for private treatment or simply going without care if we cannot afford it.

Data from the NHS Information Centre released last month shows that only 58.3 per cent of the population saw an NHS dentist in the two years ending March 2009, with the number of complex treatments, such as root canals and crowns, falling dramatically, by 40 and 50 per cent respectively, since 2004.

Ironically, the parlous state of NHS dentistry seems to have been exacerbated by the very attempt to overhaul it – labour’s 2006 dental contract.

The new contract was intended to end the old “drill-and-fill” practice whereby dentists were paid for each treatment they carried out, so the more procedures they undertook the higher their earnings. The idea behind the new contract was to encourage dentists to spend more time on preventative work, teaching patients how to care for their own teeth, thereby reducing future treatment.

Dentists are now paid a fixed contract value for the amount of work they do each year. Work is measured in UDAs (units of dental activity). Dentists now essentially have “UDA targets” to meet each year. Under the new contract, their salaries have not been cut as they had been in the early Nineties, which led to an exodus to the private sector.

Dentists are free to choose whether to provide NHS or private treatment, or a combination of the two. While many NHS dentists’ basic pay is around £90,000 in large practices, but in areas where NHS practitioners are few and far between, they can make a lot more.

Around 400 practices earn up to £300,000 a year, shared among several dentists. Private dentists earn little more – one survey in 2005 by the Health and Social Care Information Centre estimated the gap at no more that £800 a year. Most claimed to have left the NHS due to the pressure of working harder for less money, with less time to spend on each patient.

Local Primary Care Trusts (PCTs) were given responsibility for providing dental care in their areas. It is they who employ dentists, and it means that managers can offer incentives to dentists to work in their area, and thus increase patient access, eradicating once and for all the problem of how to get on an NHS dentist’s list.

But, despite these good intentions, the situation appears to have deteriorated further. According to figures from the NHS Information Centre, last year nearly 50 per cent of NHS dentists did not take on any new patients. In addition, 2,000 dentists have left the NHS since 2006. So what has gone so badly wrong?

The flaws are fundamental, says Liberal Democrat health spokesman Norman Lamb. “Many good dentists have become fed up with NHS bureaucracy, voted with their feet, and left the profession. So there is a danger that while not all the NHS dentists left are second rate by any means, we could end up with a two-tier profession.”

Lamb believes that the financial disincentive to carry out complex work is so serious it threatens to “de-skill” the profession and that far from encouraging the public to look after their teeth, “there is no incentive for the dentist to do preventative work at all.”

The public are not happy, says Dr Anthony Halperin of the Patient’s Association.”Simple procedures can end up costing the patient more than before, while there is no incentive for dentists to perform complex and time-consuming treatment. Most of all, the overwhelming public complaint is access.”

The majority of dentists are unhappy, too. One complained: “If you take on a new patient who has not been to the dentist for a few years, they might need a lot of work, and you are effectively penalised for doing it. Under the new contract, whether a patient needs one filling or 10 fillings, the dentist gets paid the same.”

Dr John Milne, chair of the British Dental Association, the professional association and trade union for dentists, adds that many complain that “the target-driven nature of the existing contract has made life difficult”. If a PCT has set targets for the number of procedures it expects to be completed, many dentists are left with no time to teach their patients about hygiene.

So what is the answer? Professor Jimmy Steele, Head of the School of Dental Sciences at Newcastle University led the recent independent review of NHS dentistry, which has just published a set of recommendations aimed at redressing the problems of access and receiving appropriate treatment (for patients) and bureaucracy and pay (for dentists). It has been Prof Steele’s unenviable task to pick apart the 2006 contract and put it back together, making it work at no extra cost to the taxpayer.

“The 2006 contract was intended to make fundamental changes in thinking. Dentistry had been pretty much unaltered since the birth of the NHS in 1948,” he says. “The idea was that the PCT would be able to buy what they wanted on behalf of their patient, making better use of resources. Previously dentists had been able to move around to where they wanted there was no ability to fit services to local needs.”

In effect, dentists could set up an NHS practice where they wanted to live, not necessarily where one was needed. “The idea of local commissioning is sensible,” he adds. “Access problems should have been addressed in time.”

The new contract also aimed to simplify payments. Previously, dentists billed the NHS centrally for any one of 400 different procedures. The more work they did, the more they got paid. “The new system, where contracts are paid on UDAs in three bands is probably too simple,” says Prof Steele. “The payment bands are wide and differ depending on where the dentist is located, on their history, sometimes on their negotiating skills.”

Dentists earn one UDA (worth between approximately £17 and £40) for a simple procedure such as a check-up, three UDAs (worth about £75 on average) for any number of fillings (in one appointment), or 12 UDAs (worth about £300) for crowns or dentures, in addition to any other treatment.

“The system is open to misuse,” says Prof Steele. “It is possible to take one tooth out and make an impression for a denture and then charge 12 UDAs which is clearly not as complex or difficult as root canal work which pays only a quarter of the fee.”

Incentives to take on new patients are not having the desired effect. Far from encouraging dentists to see more patients, it has become easier to make a living seeing existing patients more often. One of the biggest problems is taking time to put a mechanism in place for centrally collecting data, so it is difficult to know where and how the system isn’t working.

So do we need to start again from scratch? Prof Steele thinks not: “When we carried out the review it became clear that access is improving, but there is a communication problem. The public didn’t know how to find an NHS dentist. Meanwhile the PCT claimed that they were running plenty, and that all the public needed to do was ask. The public would then be saying, ‘what’s a PCT?’ Better communication could sort that problem out easily.”

Prof Steele is also recommending improvements in payment methods. “We need a blended contract, where a dentist is paid for every person on his list, and also for every treatment he carries out. We don’t want people under-treated any more than over-treated. There also needs to be a reward for quality so we need to get data back into the system.”

While Prof Steele approves of the scheme of local commissioning, Norman Lamb warns that PCT managers may not be ready. “We need to train them better, a lot of them are far too passive. You do get pockets of excellence but many don’t have the skills they need.”

Shake-ups, however worthy, cost money, and increased investment is unlikely. Dentistry is threatened by the spectre of financial cuts, as part of cuts in public services, regardless of who wins the next election.

So while the Patients Association has welcomed Prof Steele’s review, Dr Halperin, a dental surgeon who does both NHS and private work in central London, says: “We are concerned that because of funding problems, once again there will be no real improvement in the dental contract and subsequently no improvement to the services for our patients.”

The biggest challenge says Dr Milne, is to get all political parties to recognise the value of Prof Steele’s report. “We need to embrace it; it is our best chance of providing a dental service of which we can all be proud.”

Dr Milne is also optimistic: “The number of dentists in training is increasing, but we need to make the NHS an attractive place to work. And dentists who have left will only return if the NHS offers them the chance to treat their patients properly. Some might even be quite excited at the chance.”